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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-KEFUNDABLEI PERMIT (;ALL <br />JOB ADDRESS L414S G tcrK 'O1^ <br />CROSS STREET 1 el Fp n+654 �If— <br />OWNER NAME J <br />95DJ-/0y/ FOR INSPECTIONS LXPIRES 1 YEAR FROM UATE ISSUEI <br />j �7 CITY/ZIP 5/�j D, ry< � n e 14 <br />APN 1 / 9 17 / /d PARCEL SIZE S , 33 <br />PHONE <br />OWNER ADDRESS _SCj r7c' CITY/STATE/ZIP <br />�G <br />CONTRACTOR - IIC� J 4�r�� O''L C' PHONE p- S <br />�- ) <br />CONTRACTOR ADDRESS 6 6")x C'sb CITY/STATE/ZIP <br />LICENSE G' C-42 Ll C-36 OTHER NUMBER EXPIRATION DATE <br />WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br />❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # <br />TYPE OF WORK: NEW INSTALLATION REPAIR/ADDITION ENGINEER DESIGNED /ALTERNATIVE <br />REPT ACEMEAIT OUT F -SERVICE SEPTIC SYSTEM DESTPI ICT!ON <br />INSTALLATION WILL SERVE: 1RESIDENCE ❑ COMMERCIAL ❑ OTHER <br />NUMBER OF LIVING UNITS: ` NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br />p"�`SEPTIC TANK TYPE/MFG &L CAPACITY C Y O Ij gal # OF COMPARTMENTS <br />❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS <br />DISTANCE TO NEAREST: WELL /654- ft FOUNDATION Q ft PROPERTY LINE -75-f ft <br />❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) <br />Irl° LEACH LINES <br />LEACHING CHAMBERS <br /># OF LINES .3 LENGTH OF LINES O6 I ft <br />DISTANCE TO NEAREST <br />WELL 1 O6' ft <br />FOUNDATION P t ft PROPERTY LINE L ft <br />❑ FILTER BED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ MOUNDED <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ SUMPS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />❑ DISPOSAL PONDS <br />WIDTH <br />ft LENGTH <br />ft DEPTH ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ft PROPERTY LINE ft <br />SEEPAGE PITS <br />NUMBER 3 <br />WIDTH Lj"� I I <br />ft DEPTH 1z S 1 ft <br />DISTANCE TO NEAREST <br />WELL ft <br />FOUNDATION ( 25 I ft PROPERTY LINE �Q) ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />DEPARTMENTUS ONLY <br />Application Accepted By C�� Date % ��/ Area I Employee ID# A 67 <br />Final Inspection By Date�o i`2T ( ❑ SPECIAL PERMIT -Approved by <br />Character of Soil to epth of 3 t: Pit/Sump Soil Character: <br />COMMENTS NeW 5V P- 7>Fm J-1 <br />PE SC ReceivedChec Amount w <br />Permit/ Invoice # Permit ID# <br />Code INFO B ash Remitted Service Request # <br />431 10 5s <br />42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br />4/14/18 <br />